The ins and outs of internal examinations

pregnant woman with doctor
pregnant woman with doctor

Prominent on the list of least glamorous things about pregnancy is the internal examination. It’s something you’re likely to encounter several times before you finally meet your baby, but as you awkwardly climb into position for this examination, and your doctor or midwife starts the search for your cervix, you may be wishing they weren’t part of the pregnancy package.

Professor Michael Permezel, president of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, says that an internal examination (also called a vaginal examination) is routinely recommended at three points during pregnancy. The first is during early pregnancy, when you may be due for a pap smear. “Pregnancy is actually a good time to have it done,” he said. “It never causes a miscarriage, it’s a very safe thing to have done.”

Later in the pregnancy, an exam may be recommended if your caregivers are considering inducing labour. Professor Permezel says this checks if the cervix is open or closed, which helps determine the best way of induction. This doesn’t require the use of a speculum (the instrument used during a pap smear) - your doctor or midwife will use two fingers instead.

During labour, internal examinations are commonly carried out every four to six hours, says Professor Permezel, and gives information on how widely dilated your cervix is, as it needs to open to about 10cm (fully dilated) for a baby to be born vaginally. “[These examinations] ensure firstly that there is no complication of labour, and secondly, that labour progresses normally,” he said. The earlier a complication is discovered, the better the outcome for both baby and mother.

Professor Permezel said women usually understand the need to carry out this examination, which he describes as “very quick and easy”. Josie Merrick, a 33-year-old mother of three, agrees, saying she felt fairly comfortable during her internal exams. During one of her labours, Merrick’s checks revealed the birth had stalled, and she knew she had to do something different. “I walked around and my son was born 20 minutes later,” she said.

Danielle Stone, a mum of two, admitted that “they weren't the most comfortable exams, and they did hurt.” But she was happy to have the checks. “They were always helpful as they gave my care providers useful information on what was going on,” she said. “That gave me a feeling of knowledge, power and control over my labour.”

However, not all mums-to-be are willing to be examined, particularly when in the throes of labour. Korin Kritzinger, a 37-year-old mother of one, says she didn’t want to be disturbed physically or mentally during labour.

“I wanted to be as deep in the labour trance as possible,” said Kritzinger, who has trained and worked as a medical doctor overseas. “Not knowing the dilatation made it possible to be focussed on the present moment. I didn’t want to be put on a clock based on my ‘progress’.” This, she says, was part of the reason she chose a homebirth.

Hannah Dahlen, professor of midwifery in the School of Nursing and Midwifery at the University of Western Sydney, said that women feel like they have almost no right to say no to vaginal examinations – and that there’s no good evidence to support doing it routinely.

Dahlen is one of the authors of a recent review on the routine use of vaginal examinations in labour. The review found no evidence to support or refute the routine use of vaginal exams to improve outcomes for babies or their mothers in labour, and recommended urgent research be carried out on the benefits and possible harms of this practice.

Dahlen, who is carrying out further research in the field, said the first possible harm is the increased risk of infection for mother and baby. “Secondly, every time you put your fingers in and touch the cervix, you release a whole surge of hormones … you’re potentially altering the labour,” she said. “[Women] can get very distressed and want pain relief.”

Doctors and midwives also need to be mindful of the possibility of inflicting psychological trauma when carrying out the examinations; Dahlen says that as many as 20 per cent of women have experienced some sort of sexual assault, and others may have a history of other difficulties, such as a previous difficult birth, which could make the process traumatic.

While vaginal examinations are a useful tool if there’s a problem in labour, Dahlen does not believe they should be performed routinely. “Midwives are very skilled at listening to behavioural cues, watching what women do, and hearing the sounds change,” she said.

“If that doesn’t happen, then we’ll do the vaginal examination to see if there is a problem.”

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